CDEO ACTUAL TEST QUESTIONS WITH
COMPLETE ANSWER KEY
●● d. No, CDEOs review records on a proactive basis to prevent
documentation deficiencies
Clinical documentation improvement is a proactive measure. The CDS
will develop and monitor policies and procedures that affect the
documentation process. CDI should begin at the front end of all services
and care. Prevention of documentation issues is the key. See Page 1
Answer: The CDEO will focus his or her attention on records requested
for post payment review.
a. Yes, CDEOs only review records that might be an audit concern and
require physician education.
b. Yes, CDEOs only review records for paid claims by government
payers.
c. No, CDEOs do not review records unless it is requested by the
compliance officier.
d. No, CDEOs review records on a proactive basis to prevent
documentation deficiencies
●● c. Prevent deficient documentation
The CDEO will review the findings of the auditor to determine what
should be done to resolve documentation the issues on a proactive basis
to prevent documentation and compliance risks.
Answer: The CDEO will review the findings of the auditor in order to:
,a. Reprocess claims
b. Make an addendum to the medical record
c. Prevent deficient documentation
d. Know what accounts should be adjusted off
●● I, II, III, and IV
For different reasons other than reimbursement, requests for medical
records come from different sources, for a multitude of different reasons.
A few of these, other than Federal Health Care Plans, are patients who
are becoming more active in their care , attorneys seeking information
for third party liability claims or mal-practice claims, other providers
involved in the patients' care, employers for pre-employment
applications and worker's compensation cases, private payers, recruiting
offices for military applications, and the social security administration
for the patients' SSI applications.
Answer: Which of the following sources other than federal healthcare
plans may request the medical records?
I. Patients
II. Providers involved with the patient's care
III. Employers for worker's compensation claims
IV. Private payers
●● a. The appropriateness of the services provided
In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely what
,services were actually provided. The medical record may be used to
validate: (a) The site of the service; (b) The appropriateness of the
services provided; (c) The accuracy of the billing; and (d) The identity of
the caregiver.
Answer: In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely what
services were actually provided. Other than the site of service the
medical record may be used to validate:
a. The appropriateness of the services provided
b. The patient's certificate of birth
c. The identity of the patient's extended family
d. The cost of healthcare benefits used for the year.
●● c. Detailed, well documented notes
The details in a well-documented note are a provider's best defense in
any legal situation. If the record is deficient in details, there is no
"evidence" to support a provider's testimony.
Answer: A provider's best defense in any legal situation is:
a. Patient records maintained for five years
b. An experienced healthcare attorney
c. Detailed, well documented notes
d. Updated computer storage systems
●● c. During the encounter or as soon as possible
, The best way to achieve the most accurate, detailed documentation is for
the provider to document the encounter/services as soon as possible after
(if not during) the encounter.
Answer: To maintain an accurate medical record, what is the
recommended appropriate time for provider documentation?
a. Within 48 hours of patient visit
b. A minimum of bi-weekly
c. During the encounter or as soon as possible
d. The end of each day for all encounters that day
●● d. If it is documented in the patient's medical record
Quality assurance in patient care is only evident if it is documented in
the medical record. Quality services may have been provided; however,
if this is not evident within the medical record, problems may arise.
Answer: Quality assurance of patient care is only evident if:
a. The patient maintains a state of optimum health
b. Visits are only required for well-checks or injury
c. The patient survey and ROS does not change
d. If it is documented in the patient's medical record
●● b. Documentation reviews can be performed on a prospective basis.
CDI programs are intended to be performed on a prospective basis to
improve documentation deficiencies prior to claim submission. The
intent is to identify deficiencies and make the appropriate corrections
COMPLETE ANSWER KEY
●● d. No, CDEOs review records on a proactive basis to prevent
documentation deficiencies
Clinical documentation improvement is a proactive measure. The CDS
will develop and monitor policies and procedures that affect the
documentation process. CDI should begin at the front end of all services
and care. Prevention of documentation issues is the key. See Page 1
Answer: The CDEO will focus his or her attention on records requested
for post payment review.
a. Yes, CDEOs only review records that might be an audit concern and
require physician education.
b. Yes, CDEOs only review records for paid claims by government
payers.
c. No, CDEOs do not review records unless it is requested by the
compliance officier.
d. No, CDEOs review records on a proactive basis to prevent
documentation deficiencies
●● c. Prevent deficient documentation
The CDEO will review the findings of the auditor to determine what
should be done to resolve documentation the issues on a proactive basis
to prevent documentation and compliance risks.
Answer: The CDEO will review the findings of the auditor in order to:
,a. Reprocess claims
b. Make an addendum to the medical record
c. Prevent deficient documentation
d. Know what accounts should be adjusted off
●● I, II, III, and IV
For different reasons other than reimbursement, requests for medical
records come from different sources, for a multitude of different reasons.
A few of these, other than Federal Health Care Plans, are patients who
are becoming more active in their care , attorneys seeking information
for third party liability claims or mal-practice claims, other providers
involved in the patients' care, employers for pre-employment
applications and worker's compensation cases, private payers, recruiting
offices for military applications, and the social security administration
for the patients' SSI applications.
Answer: Which of the following sources other than federal healthcare
plans may request the medical records?
I. Patients
II. Providers involved with the patient's care
III. Employers for worker's compensation claims
IV. Private payers
●● a. The appropriateness of the services provided
In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely what
,services were actually provided. The medical record may be used to
validate: (a) The site of the service; (b) The appropriateness of the
services provided; (c) The accuracy of the billing; and (d) The identity of
the caregiver.
Answer: In addition to facilitating high quality patient care, a properly
documented medical record verifies and documents precisely what
services were actually provided. Other than the site of service the
medical record may be used to validate:
a. The appropriateness of the services provided
b. The patient's certificate of birth
c. The identity of the patient's extended family
d. The cost of healthcare benefits used for the year.
●● c. Detailed, well documented notes
The details in a well-documented note are a provider's best defense in
any legal situation. If the record is deficient in details, there is no
"evidence" to support a provider's testimony.
Answer: A provider's best defense in any legal situation is:
a. Patient records maintained for five years
b. An experienced healthcare attorney
c. Detailed, well documented notes
d. Updated computer storage systems
●● c. During the encounter or as soon as possible
, The best way to achieve the most accurate, detailed documentation is for
the provider to document the encounter/services as soon as possible after
(if not during) the encounter.
Answer: To maintain an accurate medical record, what is the
recommended appropriate time for provider documentation?
a. Within 48 hours of patient visit
b. A minimum of bi-weekly
c. During the encounter or as soon as possible
d. The end of each day for all encounters that day
●● d. If it is documented in the patient's medical record
Quality assurance in patient care is only evident if it is documented in
the medical record. Quality services may have been provided; however,
if this is not evident within the medical record, problems may arise.
Answer: Quality assurance of patient care is only evident if:
a. The patient maintains a state of optimum health
b. Visits are only required for well-checks or injury
c. The patient survey and ROS does not change
d. If it is documented in the patient's medical record
●● b. Documentation reviews can be performed on a prospective basis.
CDI programs are intended to be performed on a prospective basis to
improve documentation deficiencies prior to claim submission. The
intent is to identify deficiencies and make the appropriate corrections
